Difficult evaluation of thyroid cancer due to cervical paraffin injection

CASE REPORT

Copyright © 2011, the Korean Surgical Society J Korean Surg Soc 2011;81:S17-20

http://dx.doi.org/10.4174/jkss.2011.81.Suppl1.S17 Journal of the Korean Surgical Society

JKSS

Received May 6, 2011, Revised July 9, 2011, Accepted July 13, 2011 Correspondence to: Hang-Seok Chang

Thyroid Cancer Center, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 712 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea

Tel: ＋82-2-2019-3370, Fax: ＋82-2-3462-5994, E-mail: [email protected]

cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Difficult evaluation of thyroid cancer due to cervical

paraffin injection

Yong Sang Lee

, Eun Ju Son

, Bup Woo Kim

, Hang-Seok Chang

, Cheong Soo Park

1

Thyroid Cancer Center, Departments of 2Surgery and 3Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

Paraffinoma is a well known complication of previous paraffin injection into the subcutaneous layer that presents as various conditions including firm mass formation, edema, induration, ulceration, and skin necrosis. Paraffinoma can mimic neo-plasm on physical examination and imaging studies and may complicate ultrasonographic diagnoses due to typical posteri-or shadowing and high echogenicity. When paraffinomas involve around the thyroid gland, the diagnosis of thyroid tumposteri-ors is very difficult. We present a case of thyroid cancer, the evaluation of which was complicated by the presence of cervical paraffinoma.

Key Words: Thyroid neoplasms, Paraffinoma, Ultrasonography

INTRODUCTION

Paraffinoma is a chronic granuloma, caused by the pros-thetic or therapeutic injection of paraffin into tissues. It usually presents as a firm, discrete mass that can be ex-tremely painful and disfiguring. Other complications of paraffinoma include edema, induration, ulceration, and skin necrosis. Paraffinoma may occasionally mimic neo-plasm on physical examination and imaging studies [1], and may complicate ultrasonographic examination with posterior shadowing artifacts [2].

We describe a case of difficult preoperative ultrasono-graphic evaluation of the thyroid gland due to previous cervical paraffin injection. Written informed consent was

obtained from the patient for publication of this case report.

CASE REPORT

A 60-year-old woman was presented with a thyroid nodule that was incidentally discovered on routine medi-cal check-up. The patient underwent a fluorine-18-fluor-odeoxyglucose positron emission tomography scan at a local hospital and abnormal hot uptake was discovered in the left thyroid gland (Fig. 1A). She had no specific rele-vant medical history, except for paraffin injection into the neck for a neck lift 10 years ago.

Yong Sang Lee, et al.

S18

Fig. 1. (A) Fluorine-18-fluorodeoxyglucose positron emission tomography scan showing abnormal hot uptake in the left thyroid gland, (B) cervical ultrasonography demonstrating limited evaluation of the thyroid gland due to implant materials, and (C) computed tomography showing solid and cystic masses in the isthmus and left lobe of the thyroid gland (arrow). T, trachea; CCA, common carotid artery.

Fig. 2. Operative find-ings showing the gran-uloma under the subcu-taneous layer (arrow) (A), and a left hemithy-roidectomy specimen and granulomas (B).

On physical examination, multiple small nodules were noted in the neck. Cervical ultrasonography showed mul-tiple granulomas in the neck and around the thyroid gland that limited evaluation of the gland. Because of the limited view, ultrasonography-guided fine needle aspiration cy-tology failed to diagnose thyroid carcinoma. Computed tomography (CT) demonstrated solid and cystic masses in the isthmus and left lobe of the thyroid gland that ap-peared suspicious for cancer (Fig. 1B, C).

A diagnostic left hemithyroidectomy was performed for suspicion of thyroid carcinoma. Operatively, two nodules were found in the isthmus and left thyroid measuring 1.3 cm and 1.5 cm in diameter, respectively. Using an intra-operative frozen section, papillary thyroid carcinoma was confirmed in the left thyroid mass and total thyroidectomy was performed immediately. In addition, two large

pal-pable granulomas in the neck were removed (Fig. 2). Postoperative histopathological examination confirm-ed classic papillary thyroid carcinoma in the left thyroid and papillary thyroid carcinoma with nodular fasciitis- like stroma in the isthmus.

The patient was discharged from the hospital four days after surgery without any complications. She underwent postoperative low-dose radioactive iodine treatment for ablation, and an iodine-131 whole body scan showed no abnormal uptake in the thyroid bed or other areas.

The patient has received routine check-ups and meas-urements of serum thyroglobulin concentrations along with thyroid stimulating hormone suppression therapy. Follow up ultrasonography was performed at 6 months af-ter the operation, and there was no difficulty in evaluation the thyroid operation bed.

Cervical paraffin injection

thesurgery.or.kr

S19

DISCUSSION

Attempts to alter the body contour have been made since the 19th century, with numerous foreign materials introduced into different areas of the body [3]. Subcuta-neous injections of high viscosity fluids have been used for more than a century to augment and expand tissues. Paraffin, a colorless hydrocarbon mixture commonly used to make candles and lubricants, was first introduced in 1890 as a cheap and quick method of breast augmentation.

Paraffinoma is a granulomatous resection resulting from the injection of a foreign substance containing straight-chain saturated hydrocarbons such as paraffin or mineral oil. The body lacks the enzymes to metabolize in-terstitial exogenous oils, and a foreign body reaction oc-curs [4].

Macroscopically, excised specimens are white or gray-ish-white. Microscopic changes manifest macroscopically in the form of undesired reactions including inflam-mation, edema, scarring, necrosis, deformity, ulceration, and sterile abscesses [3,5]. There is granulomatous in-flammation with multiple clear vacuoles, resulting in a “Swiss cheese” appearance [6]. The histopathological fea-tures include thickening of the reticular dermis and re-placement of normal subcutaneous fat by lakes of oil inter-spersed with fibrous tissue and a granulomatous chronic inflammatory reaction [5].

Although the histopathological examination was not confirmed in our patient, the diagnosis of paraffinoma made sense in light of the physical examination findings and medical history.

Ultrasonography is the imaging modality of choice for preoperative evaluation and characterization of thyroid lesions in thyroid cancer [7]. Fine-needle aspiration cytol-ogy is the next step in the diagnosis of thyroid cancer, and is usually performed under ultrasonographic guidance for exact targeting of the lesions.

However, paraffinomas, which exhibit marked posteri-or acoustic shadowing, can complicate ultrasonographic examination of the thyroid gland and therefore limits the usefulness of ultrasonography in investigating thyroid tu-mors in patients with neck paraffinomas [2].

In the present case, ultrasonographic evaluation was

complicated by posterior acoustic shadowing of the im-plants and we chose to perform neck CT. The results of the CT scan were not diagnostic but were helpful for local-ization of the lesion in the thyroid gland when taken along with other pertinent information [8]. We performed ipsi-lateral lobectomy and an intraoperative frozen section and finally confirmed the diagnosis of papillary thyroid carcinoma.

Independent of the paraffinoma, a rare variant of nod-ular fasciitis-like stroma was confirmed postoperatively. Only 18 cases of this variant have been reported in the English literature [9]. The paraffin injection was not histo-logically correlated with this rare variant.

In conclusion, radiologic findings in the patients with previous paraffin injections may be compromised by arti-facts and lead to diagnostic confusion or misdiagnosis. Awareness of this form of augmentation and obtaining a pertinent patient history will help clinicians establish the correct diagnosis. If needed, diagnostic modalities includ-ing CT, magnetic resonance imaginclud-ing, and intraoperative frozen section should be performed to confirm the diagnosis.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Iyengar R, Saint-Cyr M, Gokaslan T, Rao R. Breast para-ffinoma. Breast J 2008;14:504-5.

2. Erguvan-Dogan B, Yang WT. Direct injection of paraffin into the breast: mammographic, sonographic, and MRI features of early complications. AJR Am J Roentgenol 2006;186:888- 94.

3. Di Benedetto G, Pierangeli M, Scalise A, Bertani A. Paraffin oil injection in the body: an obsolete and destructive procedure. Ann Plast Surg 2002;49:391-6.

4. Del Rosario RN, Barr RJ, Graham BS, Kaneshiro S. Exogen-ous and endogenExogen-ous cutaneExogen-ous anomalies and curiosities. Am J Dermatopathol 2005;27:259-67.

5. Hohaus K, Bley B, Köstler E, Schönlebe J, Wollina U. Miner-al oil granuloma of the penis. J Eur Acad Dermatol Venereol

Yong Sang Lee, et al.

S20

2003;17:585-7.

6. Uchida Y, Yoshii N, Kubo H, Kanzaki T, Kanekura T. Facial paraffinoma after cosmetic paraffin injection. J Dermatol 2007;34:798-800.

7. Stulak JM, Grant CS, Farley DR, Thompson GB, van Heer-den JA, Hay ID, et al. Value of preoperative ultrasono-graphy in the surgical management of initial and reoper-ative papillary thyroid cancer. Arch Surg 2006;141:489-94.

8. Gu DH, Yoon DY, Chang SK, Lim KJ, Cha JH, Seo YL, et al. CT features of foreign body granulomas after cosmetic par-affin injection into the cervicofacial area. Diagn Interv Radiol 2010;16:125-8.

9. Lee YS, Nam KH, Hong SW, Yun JS, Chung WY, Park CS. Papillary thyroid carcinoma with nodular fasciitis-like stroma. Thyroid 2008;18:577-8.